Thursday, November 15, 2012

New Guidelines for Newborn Circumcision

On August 27, 2012, the American Academy of Pediatrics (AAP) released a new Policy on Circumcision (1)

According to the NEW AAP policy: “…the health benefits of newborn male circumcision outweigh the risks…” The specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV.”

In the 1980’s, newborn circumcision was performed on more than 80% of all newborns. Now the rate is down to about 55%. One major reason for the large drop was the widely distributed and publicized policy, released in March 1999 from the American Academy of Pediatrics. At that time, according to the AAP, the risks of circumcision did not justify the benefits.

Thus, even in 1999, the AAP acknowledged that there were benefits to newborn circumcision, but they felt that the decision was not really a medical one since there were also minor risks. This took the medical profession out of the decision-making process. Parents were told that they had to choose or not choose the procedure based on other factors such as cultural, religious or personal preference.

What are the benefits of newborn circumcision?

Recent studies (2) have confirmed that circumcised newborn males are less prone to urinary tract infections (UTI’s) infections during their first year of life. A UTI occurs in 1% of all uncircumcised male children under age 1 and the reduction of UTI was from 3-10 fold in circumcised males (from 14 in 1000 to 2 in 1000).

Circumcision also protects males from three different sexually transmitted diseases (STD’s). It turns out that uncircumcised males have twice the risk of acquiring HIV, herpes (HSV) and human papillomavirus (HPV) as adults compared to circumcised males.

What about the risks of the procedure?

A common reason given not to perform a circumcision was concern about future diminished sexual sensation in circumcised males. This is not easy to study, but in a review of the literature (according to the NEW AAP policy): “There is fair evidence that no significantdifference exists between circumcised and uncircumcised men in terms of sexual function.”

The rate of complications of this minor procedure is quite low, on the order of 1 in 500 procedures. Bleeding, the most common complication, is usually very minor and easily treated. The rate of serious complications, such as penile injury, was less than 1 in 2,500 cases.

The AAP did not go so far as to advocate that all newborn males should have a routine newborn circumcision. But, the new policy is a significant change in direction for the organization and thus for the medical profession as well.

What about pain medication?

For many years, the policy has been to use some type of injectable pain medication such as lidocaine during newborn circumcision. The NEW policy supports this as well.

Summary

Newborn circumcision is a safe procedure. It can be performed quickly and nearly painlessly, normally taking place in the hospital soon after birth. There are proven benefits to newborn circumcision and when compared to the rare risks, we feel that these benefits outweigh the risks. We therefore advise our patients to strongly consider having their newborn males circumcised.

How many Americans have this vision of a bleak future for our children -- untold generations of men living & dying with wounded genitals. No more second-class citizenship for boys. Equal rights! No circumcision. ~Brother K

The risks may be rare, but when they come true they destroy lives. It happens enough that I can tell you a death or two with name and specifics for every year since 2000.

Let me give you an example: Google Brian Mathew Brandt. He committed suicide last year in California, at 28 years of age. His genitalia was damaged when he was circumcised as a baby and he felt mutilated and incapable of having a normal sexual life.

Last year, a 4 year old child was circumcised in Texas. The doctor had trouble stopping the bleeding and use the cauterizing tool too much, resulting in fistulas on the child's penis, which bled and hurt every time that the child urinated, to the point that the child begged to have his penis cut off and he could be a girl. http://www.courthousenews.com/2012/11/09/52144.htm

A less commonly cited statement from the Technical Report of the Policy Statement of the AAP is this: "Financial costs of care, emotional tolls, or the need for future corrective surgery (with the attendant anesthetic risks, family stress, and expense) are unknown." Well, these costs include lives completely destroyed (tell a child who grew up without glans that the benefits outweighed the risks, that won't go well), millionaire lawsuits (such as the ones that made Mogen Instruments Inc go to default), and lifetime of depression - including suicides such as Brian Brandt, such as David Reimer...

So how was that? The benefits outweighed the risks?

It's interesting how opposed that is to the statement of the Royal Dutch Medical Association, that states: "There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene. Partly in the light of the complications which can arise during or after circumcision, circumcision is not justifiable except on medical/therapeutic grounds."

"Contrary to what is often thought, circumcision entails the risk of medical and psychological complications."

The reason dear doctor that the AAP advocates circumcision is because the AAP is embedded in a circumcising culture, like the U.S. already is. Let me just ask, what other parts of the body would you be willing to give up for potential health benefits? Because that's what happens... People give up a part of their babies' bodies (and its usually not mentioned functions) in the quest of some potential benefits. So what other parts would we give up? I mean, we could prevent ingrown nails and fungus if we just remove our nails, it's not like they do too much, right?

What about eyes? We could reduce our risk of cataracts by 50% removing one eye, who needs 2? Well, we won't be able to watch 3D movies anymore but they suck anyway.

You see? It's madness.

The statement of the Royal Dutch Medical Association is based on an ethic and philosophical point of view that recognizes the right of children to not be subjected to medical treatment in lack of a disease, that recognizes the right and value of having the whole body and that values self determination.

The AAP's statement is a continuation of the old Victorian morality that developed circumcision to cure masturbators before they would contract tuberculosis or another disease due to the nervous excitement caused by their immoral pollutions, and a perpetuation of old myths and exaggeration of relative risks.

On, one last comment. If you have a few minutes, please read this open letter to pediatricians who circumcise, which I wrote last month after the yearly convention of the AAP in New Orleans. Here's the link: http://circumcisiondiaries.blogspot.com/2012/10/open-letters-to-pediatricians-who.html

The foreskin has multiple important functions for the male's penis. Removing it is akin to removing an organ in the name of prevention. We don't remove the appendix from a newborn even though young people actually die from appendicitis. Infections are rare in children who have their foreskin and are not forcefully retracted and left alone. There are many more infections to be found in baby girls. But you don't advocate removing their labia, possibly because there is no secondary commodity market for labial tissue as there is with foreskin from newborns. It is not ethical to alter the genitals of a newborn without medical indications. That is not medicine. Ethics 101. If the child can pee, let them be. No genital cosmetic surgery for newborns. Painful, unnecessary, harmful.

Doctors, with all respect - you owe it to your patients, to your ethics, and to your oath, to take these comments seriously and follow up with thorough research. The comments above are non sensationalistic, based in verifiable evidence, and given that a baby is not born with a scissors attached to his hip, perhaps this idea of circumcision is just that, an idea, like Thalidomide, or putting a woman's legs in stirrups for a birth, or the Shoe Fitting Fluoroscope.

Foreskins are very profitable, even whale foreskins are used in leather chairs.

Its so sad that mothers that have their instincts telling them not to circumcise are pursuaded by doctors even though they know its wrong. Dont doctors have to study the nervous system in med school? DO they aleast come out knowing that severing a nerve causes pain? How about a dozen thousand? Gotta love the propaganda in the United $tates. We need to support educating our citizens, circumcision is just one matter that is in danger of ignorance. There are many more.

In 2005, Stallings & Karugendo found that circumcised women in Tanzania had significantly lower HIV rates. Should we implement the findings of that study and cut our little girls as well as our little boys? Female circumcisions, sometimes coded as "orificial surgery" or "clitoridectomies," also used to be conducted in American medical settings for a variety of purported health benefits and were even covered by Blue Shields until 1977. But medicalizing any form of non-therapeutic genital cutting does not make it okay.

The AAP is not a credible institution when it comes to issues of genital cutting. Check out their policy on female genital cutting published April 26, 2010 and read with horror. The policy caused so much public outrage that it was retracted one month later. I suspect it is only a matter of time before they retract their recent statement on male genital cutting, especially since the entire rest of the industrialized world does not perform routine infant male circumcisions and is rather horrified by this statement. According to well-versed "intactivist" Dan Strandjord, 48 medical industry leaders and professionals throughout Europe have released a statement reprimanding the AAP's culturally biased stance on male circumcision. (See Dan's interview here: http://youtu.be/iPm5SrZCTLI )

To the author of this article: You have hit the tip of a giant iceberg with this circumcision article. I urge you to research the subject more carefully before you side with American doctors on this complex issue. I could not recommend Dr. Ryan McAllister's 30-minute circumcision lecture more highly. It truly must be seen by anyone making medical claims about circumcision: http://youtu.be/Ceht-3xu84I

Finally, it is important to note the documented sexual and immunological functions of the foreskin before deciding whether or not to amputate it: http://www.norm.org/lost.html

The male and female genitalia have been perfected by 50,000 years of sexual co-evolution. It may be boisterous to think we can improve upon these complex anatomical structures through reductive surgery. Many subtleties of the male sexual response are lost to circumcision: all estrogen receptors, apocrine glands, sexual lubrication, and 20,000 specialized sexual nerve endings. A full range of the sexual response should be one's birthright.

As an RN and mother, I am sure I know more about the foreskin than these physicians. The fact that it is nerve and blood vessel laden, erogenous tissue is overlooked in American culture. When you remove the foreskin from a child, you let that child grow up to never know normal and natural sexuality. It is unethical to perform "preventive" surgery on a person that does not consent to said procedure. A UTI can be treated with antibiotics, as we do in baby girls and the foreskin is no more prone to infection than any other body part. STI's are transmitted from others with STI's, not dependent on whether one has a foreskin or not. Allow the man this child will become to be the one to make a decision on whether he wants his foreskin removed. His Body, His Decision.

Literally every statistic in this article has been debunked multiple times by credible peer-reviewed sources. Please do your research. There is no medical benefit to male circumcision. It is a cultural institution. The AAP is unique among world medical organizations.

The AAP dances around the so-called "benefits" and even includes the golden sound bite "the benefits outweigh the risks."

But still, it stopped short of a recommendation, just as it did in its last statement. It is still true that there is no medical organization in the industrialized world that endorses the practice.

It ought to strike readers as odd that the supposed "benefits" which "outweigh the risks" are "not enough to recommend the procedure," these are medical professionals mind you, but enough for parents, most of whom are not medical professionals, to consider?

This is a very interesting article, as it merely seems to regurgitate the AAP statement. Now some, even those in the medical field, may be too busy to think critically about this new statement, and to examine the literature the AAP drew from, and read the technical report in its entirety, but as a mother, it is my duty to be educated on matters such as these.

As a parent yourself, I can imagine you too, consider things like elective penis surgery for your children very seriously, and looking at the numbers, I can't see how there are very 'clear, proven' benefits from neonatal circumcision, and frankly, neither does Europe, Australia, or New Zealand, and non-Muslim Asia (save imperialised South Korea and Philippines thanks to good ole USA.)

The benefits, from above: "A UTI occurs in 1% of all uncircumcised male children under age 1 and the reduction of UTI was from 3-10 fold in circumcised males (from 14 in 1000 to 2 in 1000)."

A reduction in a non-life threatening infection that only occurs in 1% of intact boys anyway? Is that supposed to be significant? From what I understand, genitourinary health is pretty well understood concerning indications, symptoms, causes, and the idea that cutting off foreskin to prevent something rare and treatable with antibiotics seems irresponsible, and a bit overkill, no? As a friend and NICU nurse in New Zealand (where circumcision rates are extremely low) explains in his article here: http://barreloforanges.com/2012/08/24/pathologising-the-foreskin-unethics-in-healthcare-a-guest-post-by-psi-randell/

Further, the AAP and this article, seem to minimise the actual rate and risk of complication. It is true the technical report admits the actual complication rate of circumcision is unknown, yet there is no call to action to study this further. It would be prudent of the folks purporting benefits to also maintain balance by examining the long-term implications of circumcision. It is interesting the AAP maintains circumcision has no ill-effects on sexuality, yet after decades of circumcising infants there is not a single comparative longitudinal study of circumcised and uncircumcised males from birth to end. However, considering the exorbitant consumption of erectile dysfunction pharmaceuticals by U.S. men, I imagine the profit-driven healthcare industry simply doesn't want to face that potential loss of profits from birth to end.

It is true, the benefits of circumcision can be achieved in less invasive ways, and any adult benefit - such as supposed lowered risk of STD's - should be left to the sexually active, informed adult. Circumcision is not a silver bullet against STD's, cancer, infection, or bathing. Removing healthy, erogenous tissue from a non-consenting patient, prophylactically, when the benefits can be achieved in less invasive ways, renders infant circumcision profoundly unethical.

The unethics of circumcision, and the underwriting of this atrocious breech of human rights is what leads parents such as my self to skepticism of your profession altogether. When can I trust my doctor when he hasn't the integrity to protect our newborn sons, the most vulnerable people in our charge?

"Maybe, if the only way something can exist in society is to force it on children, it shouldn't exist."

My family is from Germany, where circumcision never happens at all (except in very rare cases where the person is of a Muslim or Jewish minority group, and these fundamentalists are trying to make sure their blood ritual stays legal in Germany despite the circumcision ban passed in Cologne). Try telling us Germans that we are less healthy than you circumcised Americans. No, you can't. You Americans have higher rates of every single STD, and six times the rate of HIV that we have! So why the hell are you promoting circumcision for health benefits? I read that they used to promote circumcision to cure masturbation, insanity, curved spine, epilepsy, hairy palms, and blindness in American medicine, and this clinical "research" used to be highly regarded as well.

Like another commenter here, I also recommend Ryan McAllister's "must-see" lecture on circumcision: http://youtu.be/Ceht-3xu84I

Christopher Guest does a great lecture as well, but it's substantially longer. I would at least recommend the part where he covers the pseudoscience behind the purported circumcision/anti-HIV link, because he's more thorough on that subject than Ryan McAllister. Here's where it starts: http://youtu.be/gYaPcKRiA5s?t=17m47s

Also: http://www.foreskin.org/lysozyme.htm

I could go on and on with these links, but I don't know how many people will actually click them, or how many people wish to be educated by strangers in a comments thread. Considering that every single comment on this post has been negative, I might be preaching to the choir. On that note, I'm surprised that this post has not been deleted already when it has generated nothing but heat from its readers. It's a shame that it was even posted at all.